THE FOLLOWING interim measures are hereby advised while the online services of the Philippine Health Insurance Corporation (PhilHealth) are being restored, as part of its containment measures following the detection of an information security incident on September 22, 2023.
1. Member Registration - Members shall submit 2 copies of
properly accomplished PhilHealth Member Registration Form (PMRF) to any PhilHealth
Local Health Insurance Office (LHIO) with supporting documents such as proof of
identity (copy of birth certificate, ID, etc.). Registrants shall be advised by
the concerned LHIO through their given contact information to pick up their
Member Data Record (MDR) and/or ID once the documents are already available.
2. Payment of Premium Contributions - Payment of premiums by the employers shall be suspended in the collection window until access to the Electronic Premium Remittance System (EPRS) is restored to generate the Statement of Premium Account. Over the counter transactions for additional reports and settlement of arrears shall also be suspended.
• All self-paying members can remit their premium
contributions to any PhilHealth-accredited Collecting Agents (ACAs) nationwide.
The lowest amount of contribution to be accepted is P400/month based on the
existing premium rate and income floor. Payment adjustments shall be made once
the affected systems have been restored and are functional.
• The deadline of payment of premium contributions for
self-paying members for the 3rd quarter of 2023 shall be extended until October
31, 2023.
• Group partners shall be notified of the availability of
the system to facilitate the acceptance and processing of their remittances.
3. Benefit Availment - All patients availing of benefits or
those with membership and contributions concerns must be entertained and duly assisted
by the healthcare facility. Members shall submit a photocopy of their Member
Data Record (MDR) and/or PhilHealth Identification Card to the
healthcare facility.
In its absence or if patients are not yet declared or
registered, they are required to submit duly accomplished PMRF together with
supporting documents to the healthcare facility. Patients must accomplish and
submit the duly accomplished PMRF within the availment period. The date of
registration to PhilHealth shall follow the date that the PMRF was
accomplished.
Foreign nationals who wish to avail of PhilHealth benefits
are required to submit supporting documents and proof of qualifying
contributions. Hospitals and other healthcare facilities should require all
availing patients to indicate their respective contact information in the PMRF
so that they can be reached for any clarifications or follow-up.
To avail of the No Balance Billing (NBB), members may
present to the government healthcare facility any of the following documents:
MDR, PhilHealth ID, Certificate of Financial Incapacity from the medical social
worker, Certificate of Indigency from the LGU social worker, Certification from
the City/Municipal Link for 4Ps beneficiaries, any government-issued ID with
date of birth for senior citizens and lifetime members.
4. Claims Filing and other Claims Concerns - The granting of
immediate eligibility to PhilHealth benefits is absolute, thereby benefit
availment of patients shall not be denied on the basis of membership and
contributions concerns.
Pursuant to PhilHealth Advisory No. 2023-0033 the period to
file claims is further extended until October 31, 2023. This includes regular
filing and return-to-hospital claims. Manual submission of claims is encouraged
only when nearing the filing period. This is to document only the actual fulfillment
and submission of the claim within the prescribed period to avoid denial of
claims due to late filing.
While connection with Service Provider (SP) is off, the
following are recommended to avoid redundancy of encoding of claims information
by healthcare facilities through their SP:
1. For initial filing, HFs shall submit a properly
accomplished Claims Signature Form (CSF) for the documentation of stamped
received date on the passing of the 120 days filing period. 2. For refiling of
RTH claim, a copy of the RTH Letter with stamped received date by the
healthcare facility and the signed CSF will suffice for documentation.
Once the eClaims is restored and fully operational,
healthcare facilities must transmit all affected eClaims electronically for the
issuance of claims series number, including CSF with stamp received.
The documentation as recorded in the above measures 1 and 2, shall only be the
basis of computing the 120-day filing period.
To support the Cataract Pre-Surgery Authorization (CPSA)
applications, a medical certificate shall be issued by the attending cataract
surgeon attesting that the patient is diagnosed as a new case of cataract for
the intended laterality.
Existing rules on 10/50 rule and the appropriate day
interval for both eye operations shall be observed by the health care provider
to avoid denial. Late registration shall be accommodated for new case of
Chronic Kidney Diseases Stage 5 patient with filed hemodialysis claims during
the optimization period.
For information and guidance. (Mindanao Examiner)
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